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  1. Community Health Systems’ ongoing journey to zero preventable harm. | PSNet

    psnet.ahrq.gov/issue/community-health-systems-ongoing-journey-zero-preventable-harm
    July 29, 2020 - Commentary Community Health Systems’ ongoing journey to zero preventable harm. Citation Text: Simon LT, Van Buren T. Community Health Systems’ ongoing journey to zero preventable harm. NEJM Catal Innov Care Deliv. 2023;4(12). doi:10.1056/cat.23.0250. Copy Citation Format: D…

  2. Abbreviation use decreases effective clinical communication and can compromise patient safety. | PSNet

    psnet.ahrq.gov/issue/abbreviation-use-decreases-effective-clinical-communication-and-can-compromise-patient-safety
    October 29, 2017 - Commentary Abbreviation use decreases effective clinical communication and can compromise patient safety. Citation Text: Parry D, Odedra A, Fagbohun M, et al. Abbreviation use decreases effective clinical communication and can compromise patient safety. Br J Oral Maxillofac Surg. 2023;61…

  3. Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. | PSNet

    psnet.ahrq.gov/issue/medication-reconciliation-admission-and-discharge-analysis-prevalence-and-associated-risk
    December 02, 2020 - Study Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. Citation Text: Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, et al. Medication reconciliation at admission and discharge: an analysis of prevalence and associate…

  4. From identifying patient safety risks to reporting patient complaints: a grounded theory study on patients' hospital experiences. | PSNet

    psnet.ahrq.gov/issue/identifying-patient-safety-risks-reporting-patient-complaints-grounded-theory-study-patients
    December 20, 2017 - Study From identifying patient safety risks to reporting patient complaints: a grounded theory study on patients' hospital experiences. Citation Text: Gyberg A, Brezicka T, Wijk H, et al. From identifying patient safety risks to reporting patient complaints: a grounded theory study on pa…

  5. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. | PSNet

    psnet.ahrq.gov/issue/understanding-barriers-physician-error-reporting-and-disclosure-systemic-approach-systemic
    January 12, 2022 - Review Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. Citation Text: Perez B, Knych SA, Weaver SJ, et al. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem…

  6. Reducing diagnostic errors—why now? | PSNet

    psnet.ahrq.gov/issue/reducing-diagnostic-errors-why-now
    July 28, 2014 - Commentary Classic Reducing diagnostic errors—why now? Citation Text: Khullar D, Jha AK, Jena AB. Reducing diagnostic errors--why now? N Engl J Med. 2015;373(26):2491-2493. doi:10.1056/NEJMp1508044. Copy Citation Format: DOI Google Scholar PubMed B…

  7. The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. | PSNet

    psnet.ahrq.gov/issue/patient-safety-adoption-framework-practical-framework-bridge-know-do-gap
    May 26, 2021 - Commentary The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Citation Text: The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap. Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248. Copy…

  8. Safety climate, safety climate strength, and length of stay in the NICU. | PSNet

    psnet.ahrq.gov/issue/safety-climate-safety-climate-strength-and-length-stay-nicu
    February 06, 2019 - Study Safety climate, safety climate strength, and length of stay in the NICU. Citation Text: Tawfik DS, Thomas EJ, Vogus TJ, et al. Safety climate, safety climate strength, and length of stay in the NICU. BMC Health Serv Res. 2019;19(1):738. doi:10.1186/s12913-019-4592-1. Copy Citatio…

  9. Safe Administration of Medication in School: Policy Statement. | PSNet

    psnet.ahrq.gov/issue/safe-administration-medication-school-policy-statement
    May 31, 2023 - Organizational Policy/Guidelines Safe Administration of Medication in School: Policy Statement. Citation Text: Miotto MB, Balchan B, Combe L, et al. Safe Administration of Medication in School: Policy Statement. Pediatrics. 2024;153(6):2024066839. doi:10.1542/peds.2024-066839. Copy Cit…

  10. Payment innovations to improve diagnostic accuracy and reduce diagnostic error. | PSNet

    psnet.ahrq.gov/issue/payment-innovations-improve-diagnostic-accuracy-and-reduce-diagnostic-error
    December 16, 2020 - Commentary Payment innovations to improve diagnostic accuracy and reduce diagnostic error. Citation Text: Berenson R, Singh H. Payment Innovations To Improve Diagnostic Accuracy And Reduce Diagnostic Error. Health Aff (Millwood). 2018;37(11):1828-1835. doi:10.1377/hlthaff.2018.0714. Co…

  11. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. | PSNet

    psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
    July 12, 2023 - Commentary Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. Citation Text: Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resilien…

  12. With money at risk, hospitals push staff to wash hands. | PSNet

    psnet.ahrq.gov/issue/money-risk-hospitals-push-staff-wash-hands
    May 18, 2022 - Newspaper/Magazine Article With money at risk, hospitals push staff to wash hands. Citation Text: Armellino D, Hussain E, Schilling ME, et al. Using High-Technology to Enforce Low-Technology Safety Measures: The Use of Third-party Remote Video Auditing and Real-time Feedback in Health…

  13. Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. | PSNet

    psnet.ahrq.gov/issue/educational-quality-improvement-report-outcomes-revised-morbidity-and-mortality-format
    March 10, 2010 - Study Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. Citation Text: Bechtold ML, Scott SD, Nelson K, et al. Educational quality improvement report: outcomes from a revised morbidity and mortality format tha…

  14. Ebctandcfinal (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/ebctandcfinal.pdf
    May 29, 2025 - AHRQ Evidence-Based Care (EBC) Challenge Terms and Conditions Terms and Conditions: By submitting a product in response to the AHRQ Evidence-Based Care (EBC) Challenge, each team and each team member represents and warrants that:  The team and its members are the sole authors, creators, and owners of the pr…

  15. Topic 0533 Postpartum Hemorrhage NSD FINALsj (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0652-131114.pdf
    May 15, 2013 - Topic 0533 Postpartum Hemorrhage NSD FINALsj Postpartum Hemorrhage Nomination Summary Document Results of Topic Selection Process & Next Steps …

  16. A Tale of Two Stories: Contrasting Views of Patient Safety. | PSNet

    psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
    March 27, 2005 - Book/Report Classic A Tale of Two Stories: Contrasting Views of Patient Safety. Citation Text: A Tale of Two Stories: Contrasting Views of Patient Safety. Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997. Copy Citation …

  17. A multidisciplinary team approach to retained foreign objects. | PSNet

    psnet.ahrq.gov/issue/multidisciplinary-team-approach-retained-foreign-objects
    June 10, 2010 - Study A multidisciplinary team approach to retained foreign objects. Citation Text: Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Saf. 2009;35(3):123-132. Copy Citation Format: Google Scholar PubMed…

  18. Race, postoperative complications, and death in apparently healthy children. | PSNet

    psnet.ahrq.gov/issue/race-postoperative-complications-and-death-apparently-healthy-children
    August 10, 2022 - Study Classic Race, postoperative complications, and death in apparently healthy children. Citation Text: Nafiu OO, Mpody C, Kim SS, et al. Race, postoperative complications, and death in apparently healthy children. Pediatrics. 2020;146(2):e20194113. doi:10.154…

  19. Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. | PSNet

    psnet.ahrq.gov/issue/mislabeled-units-umbilical-cord-blood-detected-quality-assurance-program-transplantation
    October 19, 2022 - Study Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. Citation Text: McCullough JS, McKenna D, Kadidlo D, et al. Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation cente…

  20. The impact of a tele-ICU on provider attitudes about teamwork and safety climate. | PSNet

    psnet.ahrq.gov/issue/impact-tele-icu-provider-attitudes-about-teamwork-and-safety-climate
    May 25, 2016 - Study The impact of a tele-ICU on provider attitudes about teamwork and safety climate. Citation Text: Chu-Weininger MYL, Wueste L, Lucke JF, et al. The impact of a tele-ICU on provider attitudes about teamwork and safety climate. Qual Saf Health Care. 2010;19(6):e39. doi:10.1136/qshc.…
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